Ob-Gyn Coding Alert

Question: The ob-gyn was unable to complete a surgical procedure because the patient could not be fully sedated due to obesity (the anesthesia was not effective). She tried to perform the procedure, but because the patient was not asleep, she physically resisted even the insertion of a speculum. Is there a diagnosis code to reflect this? Should I use the discontinued-procedure modifier on the surgery?


New Mexico Subscriber

Answer: In this case, you can append modifier 53 (Discontinued procedure) to the surgical procedure because the lack of sedation is due to an extenuating circumstance related to the patient's well-being.

Appending modifier 53 signals to the payer that the ob-gyn could not complete the procedure because he was concerned about the patient's health.

Watch out: According to CPT, if a patient elects to cancel the procedure or service "prior to the patient's anesthesia induction and/or surgical preparation in the operating suite," you should not use modifier 53.

For the diagnosis, you should report 995.2 (Unspecified adverse effect of drug, medicinal and biological substance) and either V64.1 (Surgical or other procedure not carried out because of contraindication) or V64.3 (Procedure not carried out for other reasons).